A COVID-19 self-isolation monitoring module for FMUI undergraduate medical students: Linking learning and service needs during the pandemic surge in Indonesia

To ensure that students continued receiving adequate yet safe clinical exposure during the COVID-19 pandemic, the Faculty of Medicine at Universitas Indonesia (FMUI) created the Module of COVID-19 Self-Isolation Monitoring which aims to equip students with the knowledge and skill to monitor confirmed and close contact cases of COVID-19. Module development, divided into four phases: preparation, orientation, implementation, and evaluation phase, started as soon as the delta wave of COVID-19 cases forced medical students to halt their offline clinical rotations. A quantitative secondary data were obtained from student and patient satisfaction questionnaires and on students’ performance and reflection. We analyzed the distribution of module evaluation, the student’s discussion score during the module, the students’ interest in participating as Covid-19 volunteers before and after the module’s deployment, and the correlation between learning outcomes and satisfaction. A total of 372 patients were monitored by 208 students during the 4-week module. The response rates were above 80%, with the majority agreeing that students found this module well-organized and fulfilled their expectations. There was a significant increase in discussion scores from weeks 1 to 4, a significant difference in the proportion of students interested in COVID-19 volunteering before and after the module completion as well as a significant low correlation between the patient’s monitoring score sheet and the reflection essay towards the patient’s satisfaction. We should still improve tutors’ time management, tutors’ provision of triggering questions for critical thinking skills, and tutors’ feedback for students. The module met patient expectations and is expected to assist tutors in providing feedback and examples of doctor–patient communication, thus accelerating students’ competence in patient interaction. Further evaluation is needed regarding knowledge transfer, the impact on community health, and the faculty development program, especially regarding how tutors fulfill their roles as medical educators.

Introduction provide information, and refer (if symptoms worsen) without requiring face-to-face meetings under the supervision of the teaching staff. It is believed that students can still apply their clinical reasoning and critical thinking abilities through long-distance communication.
This module aims to equip students with the knowledge and skills to monitor patients who need self-isolation for confirmed COVID-19 cases and quarantine for close contact. Considering the program workflow and safety, medical students were involved in online monitoring through telemedicine under tutor supervision and expert guidance. Given that clinical students already have the skill sets to contribute according to their competency, this module also provided a good chance to nurture their professional identity as future doctors through participation in monitoring self-isolation program volunteers.
Despite the need for medical schools to adapt and provide meaningful learning experiences for future medical doctors, limited empirical studies have highlighted this concern during the pandemic. The incorporation of telemedicine in undergraduate medical curricula initiated by students or faculty has been described in different reports [13][14][15][16][17][18][19] with notes on the need of stronger evidence on the effectiveness [20,21], as reported studies within the last three years haven't delineated the results of program evaluation. Therefore, this study aimed to fill this gap by providing empirical evidence on the effectiveness of the clinical practice module, which was part of a fast response during the COVID-19 pandemic involving collaboration between teachers and students. This study will describe a clinical practice module highlighting students' clinical experience in monitoring COVID-19 patients in home isolation through a telemedicine platform. The study also aimed to evaluate students' satisfaction with the module and the tutors' facilitation, students' performance in the group, students' participation in developing COVID-19 public health education media, students' monitoring completion and self-reflection essays, and patient's satisfaction with students' monitoring. We used the Kirkpatrick framework (levels 1 and 2) [22] to evaluate the module comprehensively.

Method
This study was approved by the Research Ethics Committee of the Faculty of Medicine Universitas Indonesia (KET-1215/UN.2F1/ETIK/PPM.00.02/2021). Participants provided written consent through e-form which explained that all the data obtained through the module will be further analysed by maintaining data confidentiality.

Context
As technology develops, telemedicine has been introduced as a new form of clinical practice. Telemedicine offers many benefits by eliminating distance barriers and expanding health services to those with limited access [23]. However, this practice has not been integrated into undergraduate medical education curricula, including the Faculty of Medicine at Universitas Indonesia (FMUI). Since 2012, FMUI has implemented a 5.5-year curriculum, consisting of a 3.5-year preclinical stage and a 2-year clinical stage. During their clinical years, students are exposed to practice in academic hospitals; the new module is the first to expose students to telemedicine for clinical practice systematically. Aside from its main aim to equip students with the knowledge and skills to monitor COVID-19 patients in self-isolation, this module was also expected to introduce students to telemedicine-based practice, such as teleconsultation, professionalism in telemedicine, and managing ethical dilemmas that might occur.

Description of the module
This module was conducted over 4 weeks, from July-August 2021. Students participating in this module were fourth-year medical students of the Undergraduate Medical Program of FMUI. The total of 208 students were divided into 29 groups, with 7-8 in each. They have passed clinical rotations in basic medicine and surgery and taken their clerkship oath. The rising COVID-19 wave forced these students to halt their offline rotations. This completely online module aims to give them the necessary clinical skills in a safe, distance-learning method with learning activities such as: introductory lectures, small group discussion with tutor, plenary with resource person, and structured assignment activities (self-isolation patient monitoring, self-reflection, develop educational material), seen in Table 1. These learning activities were facilitated through google sheet form 1 , educational material videos, covid-19 guideline documents, reflection sheets, and formative tests.
The modules were organized in four phases: preparation phase, orientation phase, implementation phase, and evaluation phase. The summary of each phase illustrated in Fig 1. Preparation phase. The academic calendar allocates four weeks for this module and is mandatory for all students in clinical rotation. Two weeks were allocated to the preparation of modules before students implemented them. The module team comprises multidisciplinary staff from different departments: medical education, community medicine, child health, internal medicine, and forensic medicine. With a ratio of 1 tutor to 7-8 students, 29 groups of students were formed, and each group has one tutor who comes from different departments. In addition, we also discussed the module design and students' involvement in patient monitoring through telemedicine with the organizer of the COMIC 1 system from Cipto Mangunkusumo Hospital and SILACAK 1 system by the Ministry of Health, Republic of Indonesia organized by the DKI Jakarta health provincial district.
Orientation phase. The students were given a series of introductory lectures synchronously through the Zoom 1 platform. Essential topics such as classification, pathophysiology, clinical symptoms (including emergency conditions), progression of Covid-19 and its current management in adults, children, and elderly, monitoring for COVID-19 patients, fulfilling the criteria for home isolation, self-isolation procedures and requirements, referral protocol for Covid-19, and telemedicine system from the teaching hospital and health district office, were covered during orientation phase. These lectures were conducted on the first day of the module, covering the natural history of COVID-19 and its management. Lecture materials and references regarding those topics were uploaded to Google Drive 1 and E-learning Management Systems (EMAS) 1 Universitas Indonesia, a learning management system developed by the university. Students were also required to complete a pretest in EMAS. This helped evaluate their understanding of COVID-19 and self-isolation before monitoring patients' self-isolation. Implementation phase. This module was organized to enrich students' experience in interacting with patients through safe clinical exposure while clinical clerkship was halted temporarily due to the pandemic. Students were required to monitor a minimum of one COVID-19 self-isolation patient who was asymptomatic or showed mild symptoms. These patients Students were required to obtain each patient's consent before monitoring. The patient data could only be accessed by the respective groups to ensure confidentiality. Before monitoring, students downloaded the self-isolation monitoring sheet provided in EMAS 1 . They were required to complete the sheet daily until the patients fulfilled the discharge criteria. The module team provided 29 folders that could only be accessed by the respective groups. Students

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were allowed to upload the daily self-isolation monitoring sheet and monitoring proofs, i.e., chat screenshots, audio recordings, or video call recordings. A total of 29 academic staff members were involved as tutors for the groups. Each tutor was also granted access to the students' folder to evaluate the students' progress in monitoring. Students then discussed their followup patients, as well as recommendations, knowledge input, and feedback once a week synchronously with their tutors through zoom or other platforms. The students presented their weekly reflections on the monitoring progress, support, and challenges, along with key questions, in 2 hour plenary sessions conducted every Friday with resource person from departments of internal medicine, child health, pulmonology, anesthesiology and emergency medicine, forensic, and community medicine as well as resource person from the COMIC 1 and SILACAK 1 systems. They were also required to create educational media in groups. Topics included universal precautions, health promotion, vaccination, and adverse events following immunization. Educational media could include public posters, educational videos, social media posts, podcasts, or articles in mass media.
Evaluation phase. The learning objectives in this module include (1) Explaining the requirements and procedures for self-isolation, (2) Explaining the pathophysiology of clinical symptoms and the course of Covid-19 disease, (3) Monitoring patient symptoms through telemedicine and effective communication, (4) Reviewing signs and symptoms of the disease, dangers, and procedures for referring patients to Covid-19 referral health facilities, and (5) Providing education about Covid-19, especially on aspects of prevention for patients and families. The achievement of learning objectives was measured using standard evaluation instruments from the faculty whose content has been reviewed by the academic staff, as seen in Table 2 below:  Table 2. Standard evaluation instruments for student's evaluation.

No
Learning Objectives Instrument 1.

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Evaluation of the implementation of the module was carried out using several validated and reliable instruments. The validation of the evaluation instrument for module implementation was carried out with Exploratory Factor Analysis (EFA) on all students participating in the module (208 students) with the results of the validation and reliability are presented in Table 3. They were considered valid and reliable considering the results of the EFA analysis (KMO value > 0.8 and p < 0.05, variance explained (AVE) > 0.5, with factor loading values > 0.4 and Cronbach alpha/Internal consistency > 0.8 [24].

Design and data collection
This observational study aimed to evaluate the module using quantitative secondary data that were obtained from students' satisfaction questionnaires and patients' satisfaction questionnaires. This study also evaluated students' increase in knowledge through small group discussion scores, self-reflection scores, and educational media scores, and patient monitoring completion scores scored by tutors. At the end of the module, students were asked about their experience of becoming volunteers during the Covid-19 Pandemic before and after the module. All data obtained were analyzed using IBM SPSS version 20.

Data analysis
We analyzed the score distribution of module evaluation as well as learning objective scores during the module. Descriptive data were presented as percentages on categorical variables and mean on numeric variables/scores. The Friedman test was conducted to determine the significant increase in discussion scores from weeks 1 to 4. The Mc-Nemar test was completed to determine the significant difference in the proportion of students interested in COVID-19 volunteering before and after the module completion. The correlation test was conducted to determine the correlation between the patient's monitoring score sheet and the reflection essay toward the patient's satisfaction.

Patients
A total of 372 patients were monitored by 208 students during the 4-week module. The patient cohorts are illustrated in

Students
A total of 208 students were enrolled in this module: 84 (40.38%) men and 124 (59.62%) women with age range between 21-23 years old. They were in their first year of clinical rotation and had taken the clerkship oath. Students' satisfaction with module implementation. Table 4 presents the students' satisfaction with the module implementation. The response rate of the questionnaire was 87%, with most answers being positive (mostly agree), indicating that students found this module was well-organized and fulfilled their expectations and needs to achieve the competencies.

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Coordination of patient mapping with the module team, COMIC 1 team, and SILACAK 1 team had the highest proportion of positive answers (87%). This showed the importance of teamwork and bridging communication between the module team and students as well as with other stakeholders (Cipto Mangunkusumo Hospital for the COMIC 1 team and the Provincial Health Office for SILACAK 1 ). However, we also noted that the participation of teaching staff as tutors and resource persons could be greatly improved in the future, along with the need for more student involvement and support in the module management; shown by the lowest proportion of positive answers, only 62% students agree that the teaching staff (tutors, introductory lecture resource persons, plenary resource persons, field tutors) carried out their duties well.
Students' satisfaction with tutors. Table 5 describes the students' satisfaction with tutors. The questionnaire response rate was 100%. Overall, the students agreed that the tutors were helpful during the module. However, we should improve tutor time management, asking and responding to questions to trigger critical thinking, and giving feedback to students.

Students' reflection on supporting and inhibiting factors in monitoring patients.
Regarding self-isolation monitoring, the students were asked to reflect on the supporting and inhibiting factors they experienced through a weekly reflection form. Table 6 presents the data from the weekly reflections up to 4 th week. The weekly reflection response rates were 87.98% up to week 4. Overall, the students agreed with the supporting factors and disagreed with the inhibiting factors. Regarding inhibiting factors, a sudden increase occurred in students' disagreement that "instructions from the module team are not clear" in week 3. The results show that the module was conducted according to students' expectations for support and without meaningful obstacles and was improved along its implementation. In the plenary sessions, students also shared that the dynamic telemedicine environments with challenges in navigating communications with COVID-19 patients with different conditions in their home isolation can be overwhelming and may introduce ethical dilemmas to students; such as when the family asks the students of worsening patients to find a referral to hospital, even though it was not their responsibility or patients who refuse for referral due to his/her worsen the condition, even though the students have tried their best.
The majority of students agreed on all supporting factors, with the lowest positive answer percentage for the item "patients are enthusiastic" (74.4%). Conversely, most students disagreed on all inhibiting factors, with the lowest disagreed answer percentage for "no monitoring device is available in patients' residences". This might have been because most patients did not own monitoring devices, such as pulse oximeters and home blood pressure monitors.
Students' learning outcome evaluation. The students were also evaluated through discussion sessions. Their mean scores from four times small group discussion with tutor were 81.953 (± 5.596), 82.518 (± 5.525), 82.878 (± 6.507), and 84.092 (± 6.368), with an overall mean of 82.860. We observed a significant increase in discussion scores from weeks 1 to 4 (p < 0.001). The minimum-maximum of all discussion scores was 52.5-97.5, with 99% of students' scores above 65 (the pass limit value for undergraduate students). Students were also evaluated through the completion of the patient monitoring sheet (mean score 85.35 ± 9.990), reflection essay (mean score 87.95 ± 8.413), and educational media (mean score 84.08 ± 7.364). The final scores were calculated from discussion scores, self-reflection essay scores, completion of monitoring progress forms, and educational media assignment scores.
Students were asked whether they had experience as volunteers and whether they were interested to volunteer on completion of the module. Before the module began, there were a total of 106 students (51%) already had experience in COVID-19 volunteering, and 102  Table 7.
The questionnaire response rate was 61.1% (208 patients out of 372). Hence, patients felt satisfied with the monitoring service provided. However, the proportion of positive answers/ agreed did not exceed 70% for any item. The range of positive answers was 54.3-61.1% for all items. This is an important note for the module team and faculty because this module is expected to assist tutors in providing feedback and examples in doctor-patient communication, thus accelerating students' competence in interacting with patients.
There was a low correlation between the patient's monitoring score sheet and the reflection essay towards the patient's satisfaction. (r 0,246 with p < 0,001 and r 0,202 with p 0,003). Students with higher patient's monitoring score sheets and reflection essays tended to have higher scores in patient's satisfaction. This may be a phenomenon in which students who actively follow up and have a thorough grasp of the material tend to provide better education/monitoring, resulting in satisfied patients.

Discussion
This study has described the development of a clinical practice module that assigned students to monitor COVID-19 patients in home isolation through a telemedicine platform provided by stakeholders (teaching hospital and provincial health district office). Overall, this study showed students' satisfaction towards the module, the tutors' support and facilitation as well as their involvement in the home isolation monitoring program. Students' performance in the group discussions and in public health media production as well as in monitoring completion and students' reflective essays demonstrated very satisfactory results, Patients being monitored by the students also showed overall good satisfaction towards students' monitoring activities.
Given the need to sustain adequate clinical exposures for medical students during the pandemic and provide opportunities for medical students and the medical school to participate in Table 7. Patients' satisfaction with student's monitoring program (N = 208).

No
Items Disagree Agree

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COVID-19 pandemic control in DKI Jakarta actively, this module was expected to fulfil both expectations. This modules' preparation, implementation and evaluation stages involved stakeholders, including medical students, medical teachers from different departments, and COVID-19 telemedicine teams from hospital and primary health care.
To our knowledge, this module is the first in Indonesia, and probably Asia, to involve students in monitoring COVID-19 patients while facilitating student-patient interaction and communication skills virtually. Reports on students' run telemedicine programs during the pandemic for different purposes in patient care have been reported in different regions. For example, the medical student-run telemedicine clinic through an academic medical centreoperated syringe services program in Florida [26], the medical student-run telemedicine elective program to provide telehealth follow-up for recently discharged patients with COVID-19 in Texas [27], and teleconsultation activities under the supervision to improve clinical reasoning and evidence-based practices of medical students in Brazil [28]. The COVID-19 pandemic has caused limitations in medical students' learning process, especially those in the clinical phase. In many countries, medical schools have had to withdraw their students from clinical rotation to ensure their safety [4,5], thus limiting their exposure to clinical case management and direct interactions with patients [6]. Therefore, telemedicine-based modules implemented in this study might be a very good alternative to provide necessary clinical experience to students during the pandemic through hands-on and supervised telemonitoring experience [13,29].
In this telemedicine-based module, students were expected to develop rapport through two-way communication in educating and reassuring patients. However, students might experience several limitations in communicating through telemedicine, such as internet access issues, lack of body language, difficulty expressing emotion, resistance to technology, or patient preference for face-to-face consultation [30], some of which also took place in the current study. Patients' psychological state, such as feeling stress due to COVID-19 and being interviewed about it, might also explain why patients were less enthusiastic to be monitored through telemedicine [31]. This follows the result that the percentage of students who agreed with the statement of "patients are enthusiastic" were fewer than other statements as supporting factor. Additionally, students' limited knowledge and experience causing poorly developed rapport might have contributed to the communication barriers. In addition to the patient's medical condition, they are also more likely to be in a state of psychological stress (i.e., depression and anxiety) due to being infected by COVID-19 [26,32].
Tutors must minimize communication limitations through intensive discussion and constructive feedback with students. Tutors' experience and advice regarding doctor-patient communication help construct an ideal model of communication for students. However, their skills in giving constructive feedback and their ability to provoke students' thoughts vary. Through students' tutor satisfaction, we observed that some students felt their tutors did not give constructive feedback. This might be caused by the tutor not allocating enough time to discuss and give feedback to students [33], which was also reflected in the students' answers for the item "tutor allocates enough time to discuss with students". Students also might not feel they received constructive feedback because the feedback given by tutors tends to be oneway communication and was not necessarily in line with the students' needs. Before giving constructive feedback, it is important to identify students' skills and knowledge by asking questions and discussing their reflections on their experience [34]. However, the students' responses revealed that some tutors did not ask questions that triggered them to think critically; thus, the tutor might fail to assess students' clinical reasoning and critical thinking skills. This is an important note for the faculty to include this aspect in the faculty development program, especially regarding how tutors fulfill their roles as medical educators [35] and in optimizing provision of constructive feedback [33].
Through patient monitoring, students are expected to have learned about interprofessional collaboration. During the monitoring process, students were asked to identify internal factors (e.g. behavior, age, gender, self-hygiene, and nutrition) and external factors (e.g. family, work environment, and other environments) affecting patients' health and wellbeing. They were also encouraged to map the various factors that caused patients to experience COVID-19 infection and advocate a recommendation plan to relevant stakeholders from different professions. This was intended to demonstrate that collaboration and good communication between various professions are needed to mitigate COVID-19 [36].
This study demonstrates how telemedicine-based practice could be integrated with current medical curricula and its impacts towards students' doctor-patient communication skills in telemonitoring. Firstly, telemedicine allowed the students' involvement in the COVID-19 mitigation plan as patient navigators and educators under tutor supervision while monitoring patients during their self-isolation period. As well as providing clinical practice using a new method, this module could reflect the medical student's role during the pandemic [37]. Secondly, through this module, FMUI contributed to the government COVID-19 mitigation plan by monitoring patients' self-isolation, thus breaking the transmission chain. Thirdly, this module demonstrates how online learning and telemedicine-based modules could help students to gain clinical experience when conventional clinical learning methods need to be temporarily halted due to the pandemic. Fourthly, this module became an example and success story in developing the curriculum, as the first that incorporated telemedicine-based practice into undergraduate clinical education. Conducting clinical practice through telemedicine has become an important competency to acquire as the "Medicine 4.0" era is a near future, which means technology will be the center pillar in diagnosing and managing patients [38]. Therefore, this approach should be integrated with current undergraduate clinical education systems, not only as a curriculum adaptation due to the pandemic but also to prepare students as future doctors facing Medicine 4.0. Lastly, monitoring systems (COMIC and SILACAK) are highly dependent on the amount and quality of data to operate well. This module also demonstrated the importance of big data in managing community health problems and designing comprehensive telemedicine systems [39]. In the future, students may take part in building Indonesia's big data system that will be beneficial for healthcare services.
This study has practical and theoretical implications. First, a model of empowering students in helping to monitor self-isolating and self-quarantining COVID-19 patients can be a valuable asset in a national COVID-19 management strategy. Second, because the module was developed when COVID-19 cases were highest in Indonesia, it has added value and served as a prototype of how to involve students in a COVID-19 mitigation plan. Therefore, whenever needed, the module can be readily reinstated to allow students to contribute to the fight against COVID-19 while simultaneously performing their academic role as students. Third, this module highlights the importance of linking curriculum closer with the health system which was shown from the COVID-19 mitigation attempt involving different stakeholders. Finally, a careful plan and dynamic implementation are required to integrate telemedicine-based content in the curriculum. This includes consideration of relevant learning theories such as social cognitive and experiential learning theories in planning and implementing the telemedicine in the course. From the practice perspective, we also attempted to provide continuous support and debriefing sessions with the tutors and the resource person should the students face an ethical dilemma. At the same time, where possible, we also tried to communicate challenges encountered by the students through our stakeholders promptly. This study has several limitations. It was based on one institution's experience, and the module only involved one student batch, it might be difficult to generalize the result to other institutions. We did not have the baseline for students' telemonitoring skills before the module hence pre-post test comparison was not possible. Moreover, this study evaluated the students' satisfaction with the module and the tutors' facilitation, and their performance in the group discussion, patient monitoring completion, public health education media and self-reflection essay, and patients' satisfaction towards student monitoring. Even though such an approach was quite comprehensive, we realize that further evaluations regarding knowledge transfer in different telemedicine settings and the impact on community health levels.

Conclusion
The Module of COVID-19 Self-Isolation Monitoring was developed as an immediate response to participate in COVID-19 mitigation and in providing clinical exposures to medical students in the clinical year despite limitations during the pandemic. The module has incorporated opportunities for the students, under supervision, to conduct telemonitoring of COVID-19 patients in home isolation. There was a significant increase in discussion scores from weeks 1 to 4 and a significant difference in the proportion of students interested in COVID-19 volunteering before and after the module completion.
Based on the comprehensive evaluation, the module has met students' and patients' expectations, with some important notes for future improvement including needs to increase capacity for tutors to provide feedback and examples in doctor-patient communication, thus accelerating students' competence attainment in interacting with patients in telemedicine context. Further evaluations are needed to document knowledge transfer in different telemedicine settings and the impact on community health. Important implications of this study towards medical education in clinical years, especially in using telemedicine platforms, and in involving students to the real attempts of mitigating COVID-19 pandemic were also discussed.